After your first visit, follow-up appointment frequency will be individualized as appropriate. Office visits are required for my ongoing assessment of your clinical status and treatment needs.
Payment: Morrison clinic accepts debit card, HSA or FSA cards, or credit card payments but requires a credit card be kept on file unless previous arrangements have been made. Payment is due prior to the time of service and will be charged to the credit card on file no later than the morning of your appointment. If there is a pattern of payment being declined then we may require a deposit equal to your out of pocket responsibility before we will schedule your appointment. This deposit will be held as a credit to your account and used if your credit card is declined for a future appointment. New patient appointments will include a $40 deposit that is charged a week prior to your appointment as a way to verify your credit card on file. This deposit will be credited to your account and used towards your future out of pocket costs.
Medical insurance: As a courtesy Morrison Clinic will file your claim with an in network insurance provider. Your insurance policy is a contract between you and your insurance company. It is important that you understand your coverage and that you have verified in-network status of Morrison Clinic. Morrison clinic cannot guarantee payments of your claim. We will attempt to verify coverage, but that is not a guarantee of payment until your insurance has processed the claim. If you insurance determines that you are responsible for additional charges ( i.e. deductible, co-insurance, psychological testing etc.) then those will also be charged to the credit card on file. If your insurance denies payment of all or part of your claim then you will be responsible for the balance and the balance will be charged to the credit card on file.
Appointments: Please be careful to keep track of all your appointments. I appreciate as much notice of appointment changes as possible, as I do not schedule more than one person per appointment time. We make every effort to send you an email to remind you of your appointment but this is a courtesy email. In accordance with clinic policy, your credit card will automatically be charged for missed appointments or appointments cancelled without 48 business hours notice and your insurance company(s) will not be billed as this is not a covered benefit of medical insurance. This is necessary because a time commitment is made to you and is held exclusively for you. The fee for a late cancel or missed established patient appointment is $140.00 per 15 minutes of scheduled appointment time. The fee for a late cancel or missed initial evaluation is $560.00 (the full fee for an hour session.) Multiple missed appointments, late cancellations, or consistently rescheduled appointments may result in termination of our clinician-patient relationship.
Late Arrival: I will not be able to see patients who are significantly late for their appointments. It disrupts the schedule for the entire day and is not fair to the patients who arrive on time. If you think you may be late, please use the patient portal to reschedule.
INSURANCE AUTOMATIC CLAIM DENIALS: Certain insurance companies may delay payment due to excessively slow processing time or by requiring medical records. For some reason the insurance company may not tell patients that medical records were requested, instead they may tell patients that Morrison Clinic has coded the claim incorrectly or provided a service that should have been included in another service. We will send medical records on your behalf one time, however if your insurance does not fix their error and pay the claim within 30 days of the dates of service then the claim will be considered overdue. After each appointment, please check your Morrison Clinic billing portal and your insurance explanation of benefits to ensure that no part of your claim was denied and immediately call your insurance company if one of your claims was denied. Your insurance policy is a contract between you and your insurance company and ultimately you are responsible for ensuring that your insurance company pays Morrison Clinic for the services rendered.
Overdue Charges: If any amount is not received by us within 30 days of the date of service, then without limiting our rights or remedies, those charges may accrue late interest at the rate of 1.5% of the outstanding balance per month, or the maximum rate permitted by law, whichever is lower. If your insurance company does not pay your claims promptly then Morrison Clinic will charge the insurance company late payment penalties that have been established by the Texas Department of Insurance Prompt Pay Act. These penalties will be charged even if your insurance plan is not regulated by the Texas Department of Insurance and will be become your responsibility if your insurance does not pay. Please closely monitor your insurance explanation of benefits and ensure that either you or your insurance has paid your claim within 30 days of the date of service in order to avoid these penalties. If you have an outstanding balance you will be unable to schedule a follow-up appointment or receive services unless the balance is paid off or our billing department has set you up for a payment plan.
Collections: It is ultimately the responsibility of the patient to make sure that Morrison Clinic is paid in full for all services rendered. For all account balances in excess of 90 days past due, a late fee of $50 will be added to the balance and the account will be turned over to our collection agency if payment is not received in 15 days. The patient is responsible for any collection or attorney fees incurred in collecting balance.
Your signature below attests that you read this agreement and understand Morrison Clinic's policies. You agree to be responsible for any balance present on your account and will pay in full for all services rendered.
Your signature below authorizes Morrison Clinic to keep your signature on file for your lifetime and to charge your credit card for appointment copays, prescription processing fees, psychological testing, deductibles, missed appointments, late cancels, penalties, deposits, and any account balances. By signing this document you agree that you will not contest any of the above charges to your credit card and acknowledge that if payment is declined by a credit card payer a $25 fee will be applied to your account. Should you dispute a credit card payment you agree to pay an additional $30 processing fee for each dispute in addition to the declined credit card fee, attorney fees incurred in disputing the chargeback, and any money owed. It is important that you keep a copy of this agreement for future reference.
Please be aware that your medical insurance does not reimburse Morrison Clinic for medication management or prescription processing services provided to you in between your appointment times. As such at each of your appointments time is spent monitoring your medication and sending enough prescriptions to your pharmacy to last until your next appointment. This is done because it can take Morrison Clinic up to 48-72 business hours to process refill request and we want to minimize delays in you getting your medication filled at the pharmacy and to minimize your out of pocket costs for prescription processing fees that your insurance does not cover.
To ensure that you do not run out of your medication, incur prescription processing fees, and/or have to schedule another medical appointment we recommend YOU DO THE FOLLOWING PRIOR to your medical appointment:
To ensure that you do not run out of your medication, incur prescription processing fees, and/or have to schedule another medical appointment we recommend YOU DO THE FOLLOWING DURING your medical appointment:
To ensure that you do not run out of your medication, incur prescription processing fees, and/or have to schedule another medical appointment we recommend YOU DO THE FOLLOWING IN BETWEEN your medical appointments:
To ensure that you do not run out of your medication, incur prescription processing fees, and/or have to schedule another medical appointment we recommend that YOU HOLD YOUR PHARMACY ACCOUNTABLE TO THE FOLLOWING IN BETWEEN your medical appointments:
Should you require Morrison Clinic to provide prescription processing services in between your appointments you will be required to pay a prescription processing fee of $20.
This fee will not be covered by your insurance.
This fee will be charged to your card on file in the following situations: oided a prescription due to not having the medication in stock.
A replacement or new prescription is sent to a pharmacy on your behalf and was a result of one of the following:
Your prescription expired.
You did not allow the pharmacy 5 days to process your refill or do not want to wait for them to get your medication in stock.
Your pharmacy is not willing to get stock transferred from another location in their retail chain.
Your insurance is out of network with the pharmacy you chose.
You need the fill date of your prescription changed.
You need your prescription changed to a 90 day supply.
You ran out of your medication or will run out of your medication due to noncompliance with your medical appointments
You have refills on file at the pharmacy but have contacted Morrison Clinic instead of your pharmacy and would like Morrison Clinic to determine if you have refills available.
Any other reason a prescription needs to be sent to your pharmacy that is not due to Morrison Clinic error.
You would like Morrison Clinic to communicate with a third party to help you get your medication dispensed as a result of one of the following:
Your pharmacy will not dispense your medication due to a concern they have about the prescription and they are not willing to call our office to address their concerns.
You would like to contact Morrison Clinic instead of your pharmacy for updates on the status of your prescription being filled.
You would like to contact Morrison Clinic instead of your insurance for updates on the status of your medication prior authorization.
You will not be charged a prescription processing fee if an error on the part of Morrison Clinic led to prescriptions not being sent to the preferred pharmacy in your patient portal profile.
The following require you to schedule a medical appointment:
Your signature below authorizes Morrison Clinic to keep your signature on file for your lifetime to charge your credit card for prescription processing fees of $20 for each occurrence and acknowledges that if payment is declined by credit card payer a $25 fee will be applied to account. Should you dispute a credit card payment you agree to pay an additional $30 processing fee for each dispute in addition to the declined credit card fee, attorney fees incurred in disputing the chargeback, and any money owed. It is recommended that you make a copy of this form for your records.
Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate: compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy.
The medication history information would include medications prescribed by your health care provider at Morrison Clinic as well as other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information.
By signing this consent form you are agreeing that your provider at Morrison Clinic and Morrison Clinic staff may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.
You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it.
This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation.
Understanding all of the above, I hereby provide informed consent to Morrison Clinic enable prescription history retrieval in my electronic medical record. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.
In accordance with Morrison Clinic policy, your medical provider is not involved in workers compensation cases, disability evaluations, child custody, or other legal matters. Therefore, your lawyer will need to refer you to an appropriate psychiatric clinician.
ABOUT YOUR CLINICIAN: Amy Morrison is not a doctor. She is a physician assistant who specializes in psychiatry. As such, the formal title of doctor should not be used to address her. Amy actually prefers that you call her Amy. It is her belief that the working relationship between client and medical provider is better forged when you are both on a first name basis. Should you see your medical provider accidentally outside of the medical office, your medical provider will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge your medical provider first, your medical provider will be more than happy to speak briefly with you. As a physician assistant, state law requires Amy Morrison to collaborate with a medical doctor, even though this medical doctor is not required to be on site. The medical doctor performs a supervisory role which includes signing off on certain prescriptions and/or chart notes, monthly supervision meetings, and being available to Amy Morrison should she determine a need for collaboration in the course of your treatment.
MEDICAL TESTING, EVALUATION, AND MANAGEMENT: Your medical appointments include 2 part computerized psychological testing. The first part is a mood component that is done prior to each appointment in the office. The second component is more specific to your disorder and is completed in the clinic the day of your appointment. Computerized psychological testing is utilized to establish a diagnosis and to monitor response to treatment and is a very important tool. Some of your medical appointments may also include brief psychotherapy. Your insurance will be billed for each different service we provide prior to your appointment and the day of your appointment. Not only do our contracts with your insurance company dictate that medical evaluation and management appointments are covered, they also dictate that brief psychotherapy and psychological testing are covered services. However all or part of these services may fall under your deductible.
APPOINTMENTS: It is your responsibility to make your health a priority in your life. Making your health a priority means that you invest the necessary time and money in order to achieve optimal health. As such it is expected that you will take responsibility to schedule appointments when needed and to attend those appointments.
THE FOLLOWING REQUIRE AN APPOINTMENT:
-New prescriptions and medication refills.
-Any adjustment that needs to be made to your current medications.
-If you are having problems with your medication such as side effects or if you feel they are not effective in managing your symptoms.
-If you or a loved one notices a change in your mood or personality.
LENGTH OF APPOINTMENTS: The length for established patient appointments are 15 minutes, we respect your time and will try to remain on schedule. Please limit the number of issues per visit if possible to ensure your pressing concerns can be addressed. When scheduling your appointment you are welcome to make additional follow up visits for the rest of your concerns or request a 30 minute appointment. Your clinician may also schedule your appointment for 30 minutes or more if deemed necessary and you will be able to determine the length of your scheduled appointment in your patient portal.
PRESCRIBING OF PSYCHIATRIC MEDICATION: In order to provide appropriate treatment, we insist that your Morrison Clinic clinicians will be the only clinicians prescribing your psychiatric medications. This includes antidepressants for the the treatment of psychiatric illness, sleep aids, and as needed anxiety medication unless you are being seen by a psychiatric provider in a hospital or emergency room setting.
PHONE CONSULTS: In order to provide the best quality care, treatment is not conducted over the phone. In rare and extenuating circumstances you can request a phone consult if you are unable to come to the clinic for an appointment. If your family member, friend, or employer would like to discuss your treatment or care they are welcome to come to your appointments. If they are unable to attend they can request a phone consult. Insurance does not cover phone consults so your credit card on file will be charged for the full fee of $140 for 5-15 minutes.
LAB WORK: I recommend laboratory values on all of my patients at least yearly, as there are many physiological factors that play a large role in mood and sleep. You can use your primary care physician or the laboratory of your choice (patients with insurance need to find out which laboratories accept their insurance). The lab will bill you or your insurance company directly. Refusal to follow through with requested lab work is considered medical non-compliance. If you are being prescribed a controlled medication or I suspect illicit drug use I may insist you complete a drug screen and failure to do so in a timely manner is considered medical non-compliance.
MEDICATION USE PRECAUTIONS: Any medication can impair thinking or reaction time until your body gets accustomed to it. Therefore, do not operate hazardous machinery, including automobiles or do anything potentially dangerous until you are certain any newly prescribed medication(s) do not affect your abilities. It is necessary to notify me and all your other doctors of any and all changes in prescribed and over-the-counter medicines including “herbal/natural” remedies.
Contact me if you experience any unanticipated medication effects including a skin rash, as that indicates a medication allergy. I advise you not to consume alcohol, including beer or illicit drugs, while taking medication, as this will prevent your medications from working optimally and the combination can be physically dangerous.
Mixing alcohol and illicit drugs with your medication or taking more than what is prescribed is considered medical non-compliance, which may result in discontinuation of treatment.
If you or someone else takes more than the recommended dose of a medicine, contact poison control or call 911.
Do not allow others to take your medicine and do not take medications prescribed for someone else. Keep all medications out of the reach of children and impaired adults.
WOMEN: Please notify me immediately of any pregnancy or intent to become pregnant, as most medications should be discontinued prior to conception. If you are of childbearing age it is recommended that you use a minimum of one form of birth control, but ideally two forms of birth control if you are being prescribed medication. Waiting to stop medication until you miss a menstrual cycle and discover you are pregnant exposes your baby to medication during the critical periods of organ development and can lead to birth defects. Whenever possible, psychiatric medications should not be used at any time during pregnancy or while breastfeeding.
CONTROLLED AND SCHEDULED MEDICATIONS:Lost or stolen prescriptions for a controlled or scheduled medication may not be replaced or filled early.
NO CONCEALED HANDGUNS ALLOWED AT MORRISON CLINIC: Pursuant to Section 30.06, Penal Code (trespass by holder of license to carry a concealed handgun), a person licensed under Subchapter H, Chapter 411, Government Code (concealed handgun law), may not enter this property with a concealed handgun
Your signature below indicates that you have carefully read, understand and accept all the terms of this Agreement and that you are hereby giving your consent for medical evaluation and treatment by Amy Morrison, Physician Assistant. You acknowledge that your treatment at Morrison Clinic requires your active participation and that you will not start taking a new medication until you feel your questions have been answered and the risks and benefits of medications have been explained to your satisfaction. You agree to take your medication as prescribed, abide by the terms set forth in this consent form including but not limited to our no concealed handgun policy. It is important that you keep a copy of this agreement for future reference.
Contact me if you experience any unanticipated medication effects including a skin rash, as that indicates a medication allergy. I advise you not to consume alcohol, including beer or illicit drugs, while taking medication, as this will prevent your medications from working optimally and the combination can be physically dangerous.
Do not allow others to take your medicine and do not take medications prescribed for someone else. Keep all medications out of the reach of children and impaired adults.
CONSENT TO CONTACT EMERGENCY CONTACT
I hereby consent for Morrison Clinic to contact the above emergency contact in the event of an emergency. This consent shall remain in force during my treatment at Morrison Clinic and for 90 days following my last appointment unless expressly revoked by me in writing.
By providing an e‐mail and telephone number to Morrison Clinic, I hereby consent to the following: Contact by Morrison Clinics (MC) via e‐mail communication at the personal address below and via text or voicemails at the phone number below. I consent that I am 18 years old or older. I acknowledge e‐mails, texts, or voice mail may be viewed or heard by unintended persons. I understand that e‐mails are not sent by way of encryption. E‐mail, text, or voice mail communication may be seen and/or heard, received and/or responded to by any staff at Morrison Clinic. E‐mail, text, and phone calls are not intended for clinical purposes or as a replacement to medical appointments or therapy but may be used as a simple adjunct to my medical care or for administrative purposes (i.e. copies of claims or superbills, billing, appointment reminders, satisfaction surveys, events, etc.). I release and hold harmless Morrison Clinic and Morrison Clinic staff for any claim(s) I may have, past, present and future, arising from the use of e‐mail, text messaging, or voice mails. This consent will remain in force until I provide written revocation to Morrison Clinic.
By signing below you acknowledge that you have received this copy of "Notice of Privacy Practices." You can copy the below text and paste into a document for your records.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Aviso en español. Si quiere este aviso en español, llame gratis al 2-1-1 o al 1-877-541-7905.
About this Notice:
Effective date: This Notice takes effect on July 20, 2015 and stays in effect until replaced by another notice.
This Notice is required by HIPAA (the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. §1320d, et seq., and regulations adopted under that act).
In this Notice, “agency,” refers to the Texas Department of State Health Services.
This Notice tells you about: (1) your privacy rights, (2) the agency’s duty to protect health information that identifies you, and (3) how the agency can use or share health information that identifies you without your written permission. This Notice doesn't apply to health information that does not identify you or your legally authorized representative.
In this Notice, "You” or “your" means you, the individual to whom this Notice is addressed or your legally authorized representative.
In this Notice, "health information" means:
• Medical information or legally protected health information about you whether in oral, paper or electronic form that relates to:
• Your past, present, or future physical or mental health or condition;
• Health care provided to you; or
• The past, present, or future payment for providing your health care.
• Genetic information about you, and
• Health Information created or received by a health-care service provider, health plan, public health authority, employer, life insurer, school or university, or health-care clearinghouse.
The agency reserves the right to change the terms of this Notice. The new Notice will be sent to your most recent address that the agency has on file. It is your duty to promptly tell the agency if you have had a change of address. The practices in the new Notice will apply to all the health information the agency has about you, regardless of when the agency received or created the information.
The agency is considered a "hybrid covered entity," which means that only certain parts of the agency have health care components and others are not. This Notice applies to the parts of the agency that are health care components, or are serving as a health care provider (for example, agency state mental health hospitals and the agency Laboratory), health plan services known as "Texas Health Steps" and the agency's Centralizing Billing Services health care clearinghouse.
Your privacy rights:
The law gives you the right to:
• Receive adequate notice of: (1) the uses and disclosures of protected health information that can be made by the agency or your health-care service provider, (2) your rights related to your health information, and (3) the agency’s and health-care service provider’s legal duties to protected health information, with some legal exceptions. The agency provides you this notice via this Notice of Privacy Practices, which is also available online on the agency's website: www.dshs.texas.gov.
• Ask the agency or your health-care service provider to restrict certain uses or disclosures of health information about you. The agency is not required to agree to these requests, except in some cases when you request that we not disclose information to your health plan about services for which you paid with your own money in full. The agency may require your request to be in writing.
• Request confidential communications about your health information and make reasonable requests to get information in a different way or location. The agency or health-care service provider may require the request to be in writing with a statement or explanation for the request. For example, you might explain that sending information to your usual address might put you in danger. You must be specific about where and how the agency can contact you.
• In some situations, look at or get a copy of certain health information, including laboratory test results that the agency or your health-care service provider has about you.
• Ask the agency or your health-care service provider's privacy office to correct certain information about you if you believe the information is wrong or incomplete. Most of the time, the agency can't change or delete information, even if it is incorrect. If the agency or health-care service provider decides it should make a correction, it will add the correct information to the record and note that the new information takes the place of the old information. The old information will remain in the record. If the agency or health-care service provider denies your request to change the information, you can have your written disagreement reviewed by the agency's privacy officer and placed in your record.
• Ask for a list of disclosures the agency or health-care service provider has made of certain health information.
• Ask for and get a paper copy of this Notice from the agency or its privacy office.
• Cancel permission you have given the agency or your health-care service provider to use or share health information that identifies you in some cases, unless the agency or health-care service provider has already taken action based on your permission. You must cancel your permission in writing and deliver it to the agency's privacy office.
• In some situations, be notified by letter from the agency's privacy officer if your health information has been used or shared in an unauthorized manner.
• Be notified of material changes to the way the agency uses or shares health information about you. All changes to the Notice will be posted on the agency’s web site and the revised Notice will be available to you at your health provider’s office.
• For all notices to, or requests for copies of information from, the agency or health-care service provider’s privacy office, please see the “Complaints and Questions” section for contact information.
The agency’s duty to protect health information that identifies you:
The law requires the agency to take reasonable steps to protect the privacy and security of your health information. It also requires the agency to give you this Notice, which describes the agency's legal duties and privacy practices. In most situations, the agency can't use or share health information that identifies you without your written authorization, except to carry out treatment, payment for your health care or the agency's health-care operations, or as required by law, as described below. This Notice explains under what circumstances the agency can use or share health information that identifies you without your permission. The agency is required to abide by the terms of the notice currently in effect.
Agency workforce (employees, trainees, volunteers and staff augmentation contractors) are trained and required to protect your health information. The agency does not give employees access to health information unless they need it for a business reason. Business reasons for needing access to health information include but are not limited to making benefit decisions, paying bills and planning for the care you need. The agency will punish employees who do not protect the privacy of health information that identifies you, according to law and agency policy.
The agency will notify you if your unsecured protected health information is breached, as required by law. The agency is required to notify you even if there is no reason to suspect any misuse of the protected health information. You will be notified by mail or by phone as soon as reasonably possible. It is your duty, or the duty of your legally authorized individual, to promptly tell the agency if you have had a change of address.
Uses and disclosures that might require your written authorization:
Agency uses or disclosures that might require your authorization include but are not limited to the following:
1. Psychotherapy notes. The agency must get your authorization, in some cases, to disclose your psychotherapy notes (certain notes that are taken by your mental health professional during the course of a counseling session) except:
• To carry out treatment, payment, health-care operations, or as required by law,
• For use by the originator of the psychotherapy notes for treatment,
• For use by the agency for its own training programs, or
• For use by the agency to defend itself in a legal action or other proceedings brought by you or your legally authorized representative.
2. Marketing. If applicable, the agency will not use or share your health information without your authorization for marketing communications about a product, such as a drug or medical device, or services that encourage you to buy or use a product or service, except if the communication is in the form of:
• A face-to-face communication made by the agency to you, or
• A promotional gift of little value provided by the agency.
If the marketing involves direct or indirect payment to the agency from a third party, the authorization must state that such payment is involved. The following activities are not considered marketing and don't require your authorization:
• Refill reminders or other communications about a drug or biologic that is currently being prescribed for you, as long as any payment received by the agency in exchange for the communication is reasonably related to the agency’s cost of the communication.
• Certain treatment and health-care operation activities, except where the agency gets payment in exchange for making the communication.
3. Sale of Protected Health Information. The agency will not sell your protected health information to any other person in exchange for direct or indirect payment, except:
• To another health care provider, health plan or healthcare clearinghouse for treatment, payment, or health care operations; or
• To perform an insurance or health maintenance organization function authorized by law; or
• As otherwise authorized or required by state or federal law.
"Sell" or a "sale" means disclosures by the agency or its business associate where there is a direct or indirect payment from or on behalf of the third-party that gets the protected health information in exchange for payment.
4. Fundraising. If applicable, the agency must get your written authorization if it shares your protected health information for fundraising purposes, except the agency may use or share the following health information with a business associate or to an institutionally related foundation:
• Demographic information relating to an individual, including name, address, other contact information, age, gender, and date of birth; and
• Dates of health care provided to an individual;
• Department of service information;
• Treating physician;
• Health outcome information; and
• Health insurance information.
For example, the agency might participate in fundraising activities, organized by its state mental hospitals’ volunteer services councils that are designed to improve the quality of patient care. These volunteer services council fundraising events are strictly voluntary and might include art shows, walks, runs, or bike rides. You must first provide the agency with your written authorization for any instance in which you choose to share your protected health information for such fundraising purposes.
5. The agency will never use genetic information for underwriting purposes.
Uses and disclosures that do not require your written authorization:
1. Treatment. The agency can use or share your health information with other health-care providers involved with your treatment. For example, the agency may provide your information to other providers so you can be seen by a specialist health-care provider for a consult. Or, if you are in a hospital, you may be treated by multiple health-care providers who have your information. By getting your information, health-care service providers will better understand your health history, which could help them provide your health care.
2. Payment. The agency can use or disclose certain health information about you to pay or collect payment for your health care. For example, when your health-care service provider sends a bill to the agency or your health plan, it includes certain information about your condition and treatment. Another example would be when the agency uses or discloses your health information to determine either your eligibility for government benefits in a health plan, or whether the proposed treatment is covered by your insurance.
3. Health-care operations. The agency can use or share health information about you for its health-care operations. The agency's health-care operations include but are not limited to:
• Conducting quality assessment and improvement activities,
• Reviewing the competence, qualifications, and performance of health-care professionals or health plans,
• Training health-care professionals and others,
• Conducting accreditation, certification, licensing, or credentialing activities,
• Carrying out activities related to the creation, renewal, or replacement of a contract for health insurance or health benefits,
• Providing, receiving or arranging for medical review, legal services, or auditing functions, and
• Engaging in business management or the general administrative activities of the agency.
The agency can also share health information about you with the agency’s business associates (contractors) or it’s the business associate’s subcontractors, if the business associate or the subcontractor:
• Needs the information to perform services on behalf of the agency, and
• Agrees to protect the privacy of the information according to agency standards.
Other examples of uses and disclosures for health-care operations by the agency include but are not limited to using or disclosing health information for case management; ensuring the agency's health-care service provider is qualified to treat individuals; or auditing a health-care service provider's bill to ensure the agency has been billed for only care you received. The agency also can contact you to tell you about treatment alternatives or additional benefits you might be interested in.
4. Government Health Benefits. If you apply for or enroll in government health benefits provided by the agency, such as Medicaid benefits, the agency can use or share health information about you in order to:
• Establish your eligibility for health benefits;
• Determine the amount of Medical Assistance to be provided to you;
• Provide health services to you; and
• Conduct or assist with an investigation, prosecution, or civil or criminal proceeding related to your health benefits.
5. Family members, other relatives, guardians, legally authorized representatives (LAR) or close personal friends. The agency can share your health information, with your agreement, or in an emergency if you are incapable of agreeing, or as otherwise authorized by law, with a family member, other relative, guardian, legal authorized representative, or close personal friend:
• When directly relevant to such person's involvement with your health care or payment related to your health care; or
• To notify the person of your location, general condition, or death.
Your "family" or "relative" means:
(1) Your dependent, or
(2) Any other person who is your first-degree, second-degree, third-degree, or fourth-degree relative, such as your:
• Parents, spouses, siblings, and children.
• Grandparents, grandchildren, aunts, uncles, nephews, and nieces.
• Great-grandparents, great-grandchildren, great aunts, great uncles, and first cousins.
• Great-great grandparents, great-great grandchildren, and children of first cousins.
The agency can make reasonable inferences of your best interest in allowing a person to act on your behalf such as to pick up prescriptions, medical supplies, X-rays, or other similar forms of protected health information, unless disclosure of the information is prohibited by law, such as substance use disorder information.
6. Substance Use Disorder Program Information. The agency is prohibited by law from sharing substance use disorder information about you or information that identifies you as seeking or getting substance use disorder treatment from a substance use disorder provider, program or facility to anyone, including family members, relatives, or friends without your written permission, unless permitted by law, for example in a medical emergency.
7. Mental Health Information. The agency will not share information about your mental health (information about your identity, diagnosis, evaluation, or treatment that are created or maintained by a professional for diagnosis, evaluation, or treatment of any mental or emotional condition or disorder, including alcoholism or drug addiction), unless expressly authorized by law.
8. “Required by law” uses or disclosures of PHI. The agency may use or disclose your protected health information to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law, for example:
A. To Government programs providing public benefits. When administering a program providing public benefits, the agency may disclose protected health information relating to the program to another HIPAA-covered entity that is a government agency administering a government program providing public benefits if:
• The programs serve the same or similar types of people, and
• The disclosure of protected health information is necessary to coordinate or improve how the programs are run.
B. For Health oversight activities. The agency might use or share health information about you to a health oversight agency for health oversight activities authorized by law. A health oversight agency must be a government agency or someone acting on behalf of a government agency.
C. For Public health activities. The agency can share health information about you as required by law for public health purposes, such as:
• A public health authority for purposes of preventing or controlling disease, injury, or disability.
• An official of a foreign government agency who is acting with the public health authority, and
• A government agency allowed to get reports of child abuse or neglect.
D. Victims of abuse, neglect or domestic violence. The agency may disclose protected health information about you if the agency reasonably believes you to be a victim of abuse, neglect, or domestic violence to a government authority, including a social service or protective services agency authorized by law to receive reports of such abuse, neglect, or domestic violence, to the extent the disclosure is required by law and the disclosure complies with and is limited to what the law allows if:
• You agree to the disclosure;
• A law authorizes disclosure; and
• The agency, in the exercise of professional judgment, believes the disclosure is necessary to prevent serious harm to your or others, or
• If you are unable to agree because you are incapacitated, a law enforcement or other public official authorized to receive the report represents that the protected health information for which disclosure is sought is not intended to be used against you and is needed for immediate action.
If the agency makes a report under this section, the agency will tell you or your legally authorized representative about the report unless:
• The agency in good faith believes that telling you would place you at risk of harm; or
• The agency reasonably believes your legally authorized representative may be responsible for the abuse and telling that person would not be in your best interests.
E. Serious threat to health or safety. The agency can use or share health information about you if it believes the use or disclosure is needed:
• To prevent or lessen a serious and immediate threat to the health and safety of a person or the public and the disclosure is made to a person reasonably able to lessen or prevent such a threat;
• For law enforcement authorities to identify or catch an individual who has admitted participating in a violent crime that resulted in serious physical harm to the victim, unless the information was learned while initiating or in the course of counseling or therapy; or
• For law enforcement authorities to catch an individual who has escaped from lawful custody.
F. For other law enforcement purposes. The agency can share health information about you to a law enforcement official for the following law enforcement purposes:
• To comply with certain legal reporting requirements;
• To comply with a grand jury subpoena;
• To comply with an administrative request, such as a civil investigative demand that is specific and limited in scope, if the information is relevant to a legitimate law enforcement inquiry and de-identified information cannot reasonably be used;
• To identify and locate a suspect, fugitive, witness, or missing person, as long as the information provided to law enforcement is specifically authorized by law;
• In response to a request for information about an actual or suspected crime victim, if either:
• The individual agrees to the disclosure; or
• The requesting law enforcement official represents that the information is not intended to be used against the victim, is needed to determine whether a violation of law has occurred, and the agency determines that disclosure is in the best interests of the individual;
• To alert a law enforcement official of a death that the agency suspects is the result of criminal conduct; or
• To report evidence of a crime on the agency’s property.
G. For judicial or administrative proceedings. The agency may share your health information in the course of any judicial or administrative proceeding with:
• A court order to share your health information from a regular or administrative court;
• A subpoena or request by a party to a lawsuit that the agency is also a party to, except a court order is required to disclose substance use disorder information, and the agency may ask the court for a protective court order.
• In some situations, you or your legally authorized representative will be notified of the request for your health information in the proceeding.
H. To the Secretary of U.S. Department of Health and Human Services. The agency must share health information about you to the Secretary of U.S. Department of Health and Human Services for legal compliance purposes.
I. Research. The agency can use or share health information about you for research:
• If certain information about you is removed so that it is de-identified,
• If you authorize the research,
• If the research is approved by an Institutional Review Board or Privacy Board, or
• As otherwise authorized by law
Your health information also can be used:
• To allow a researcher to prepare a research protocol, as long as the researcher
• demonstrates that this information is necessary for the research
• does not remove the information from the agency, or
• agrees to keep the information confidential, or
• To allow a researcher to obtain information about people who have died, as long as the researcher
• represents that the information is necessary for research that involves information about people who have died, and
• provides, when requested, evidence of the death of the person whose information is sought
J. Correctional institutions and other law enforcement custodial situations. The agency may disclose an individual’s health information to a correctional institution or law enforcement official that has lawful custody of that individual, as long as the institution or official tells the agency that the information is necessary:
• To provide that individual with health care;
• To protect the health of safety of that individual or others related to the activities of the correctional institution; or
• As otherwise required by law.
K. Other uses and disclosures. The agency can otherwise use or share health information about you:
• To create information that is de-identified and doesn't identify you.
• For military or veteran activities as required by law.
• For purposes of lawful national security activities.
• To federal officials to protect the president of the United States and others.
• To comply with workers’ compensation laws or similar laws.
• To tell coroners or funeral directors about your death as required by law.
• As otherwise required or permitted by local, state or federal law.
Complaints and questions about the use or disclosure of your information:
If you believe your privacy rights have been violated, contact the agency. You may contact the agency if you: (1) have questions about this notice, (2) need more information about your privacy rights, (3) need a physical address for the agency, or (4) are requesting a copy of health information from the agency:
• Texas Department of State Health Services (DSHS): Call 1-512-776-7111 or 1-888-963-7111 (toll free) or email firstname.lastname@example.org.
• To request your results of lab tests performed by the DSHS Laboratory, please call (512) 776-7318 or visit www.dshs.texas.gov/lab/patientresults.aspx.
• If you are receiving care from a DSHS state-operated hospital, contact the hospital’s privacy office, or
• You may also contact: DSHS Consumer Services and Rights Protection/Ombudsman Office by mail at Mail Code 2019, P.O. Box 149347 Austin, TX 78714-9347; or by telephone at (512) 206-5760 or (800) 252-8154 (toll free).
If you believe the agency has violated your privacy rights, you also can file a complaint with the:
Office of Civil Rights
U.S. Department of Health and Human Services
1301 Young St., Suite 1169
Dallas, Texas, 75202
Voice Phone (800) 368-1019
FAX (214) 767-0432
TDD (800) 537-7697
For complaints about a violation of your right to confidentiality by an alcohol or drug abuse treatment program, contact the United States Attorney’s Office for the judicial district in which the violation occurred.
The agency prohibits retaliation against you for filing a complaint.
ISP 01 (07/2015)
Last updated February 10, 2017
*This notice of Privacy Practices was obtained from dshs.texas.gov/privacypractices.aspx and was not created by Morrison Clinic.
HIPPA AND USE OF PHI CONSENT
By signing below, I acknowledge the following:
1. I have been offered the “Notice of Privacy Policies and Clients Rights.”
2. I have consented to treatment provided by the Morrison Clinic and its employees or designees (caregivers). I understand the Morrison Clinic serves as a training ground for mental health professionals and that I may be seen by a student who will provide care to me under the supervision of a licensed professional. I authorize the services deemed necessary or advisable by my caregivers to address my needs.
3. I authorize use and disclosure of my personal health information for the purposes of diagnosing or providing treatment to me, obtaining payment for my care, or for the purposes of conducting the healthcare operations of the Morrison Clinic. I hereby authorize the Morrison Clinic to release any information required in the process of applications for financial coverage for the services rendered. This authorization provides that the Morrison Clinic may release objective clinical information related to my diagnosis and treatment that may be requested by my insurance company (if applicable) or its designated agent or that maybe viewed by my credit card company should Morrison Clinic need to provide supporting documents to refute a credit card chargeback.
4. I authorize and request my insurance plan(if applicable) pay directly to the Morrison Clinic the amount due for services rendered to the patient, myself, or others covered by the above insurance plan(s). I authorize the release of any medical, mental health, or substance abuse information necessary to process insurance claims for services rendered. I understand this consent is subject to revocation at any time, except where action has already been taken on the basis of this release. Unless revoked earlier, this consent will be null and void 180 days after the final payment has been received on this account. This consent is subject to state and federal confidentiality regulations.
5. I agree to take full responsibility for the entire amount due for any and all services rendered. If the provider is contracted with my insurance company, I will be responsible only for the co‐pay, co‐insurance, deductible, penalties for late payment, and non‐covered services as determined by the insurance plan. If I do not inform the Morrison Clinic in a timely manner of any changes to my insurance coverage, I understand that I may need to pay for services in full if payment is denied in part or in full by my insurance carrier. I further understand that I may not be able to schedule appointments if my account becomes delinquent and/or my account is turned over to collections.
6. I understand that my patient records are the property of the Morrison Clinic and shall be treated as confidential; that the Morrison Clinic will conduct routine patient audits to insure quality record maintenance; that my records will not be released without my written consent or as provided by the laws of the State where I am receiving treatment. I understand that if I choose to have my records or treatment updates provided to a third party, I must request this in writing using the Morrison Clinic's “Authorization for Use and Disclosure of Protected Health Information” form or another acceptable form, with the exception of information I have agreed to release per this acknowledgement.
7. I acknowledge that if I need to cancel or reschedule an appointment I will provide a minimum of one business day’s notice. Otherwise, I understand that I am subject to the full charge for the missed appointment and am responsible for payment in full.
8. I attest that I am seeking care at the Morrison Clinic strictly for medical needs, not for any type of litigation or disability purposes. If in the course of my care, I become involved in litigation and need the Morrison Clinic to provide any type of report, testimony or other litigation required services, I understand I am fully responsible for any fees for these services and that these fees are payable in full and in advance of services.
9. I acknowledge that the Morrison Clinic is not a 24/7 care facility or a walk-in clinic and that I am responsible for seeking care at my nearest emergency center or through another caregiver of my choice when my Morrison Clinic caregiver is not available.
10. Lastly, I certify that all the information I have provided above is true and correct.
Tele-psychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. The interactive electronic systems used in Tele-psychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption and are HIPPA compliant.
• Increased accessibility to psychiatric care.
• Patient convenience.
As with any medical procedure, there may be potential risks associated with the use of Tele-psychiatry. These risks include, but may not be limited to:
• Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate decision-making by your provider.
• Your provider may not be able to provide medical treatment using interactive electronic equipment nor provide for or arrange for emergency care that you may require.
• Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
• Security protocols can fail, causing a breach of privacy of confidential health information.
• A lack of access to all the information that might be available in a face to face visit, but not in a Tele-psychiatry session, may result in errors in judgment.
Traditional face-to-face sessions in your provider’s office.
• I understand that the laws that protect the privacy and confidentiality of medical information also apply to Tele-psychiatry.
• I understand that pursuing treatment via tele-psychiatry is a decision I made and that I may withdraw my consent to the use of Tele-psychiatry during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
• I have the right to inspect all medical information that includes the Tele-psychiatry visit. I may obtain copies of this medical record information for a reasonable fee.
• I understand that my provider has the right to withhold or withdraw consent for the use of Tele-psychiatry during the course of my care at any time.
• I understand that the all rules and regulations that apply to the provision of healthcare services in the State of Texas also apply to Tele-psychiatry.
• I will not record any Tele-psychiatry sessions without written consent from my provider. I understand that my provider will not record any of our Tele-psychiatry sessions without my written consent.
• I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
• I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for Tele-psychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I must be a resident of the State of Texas and be located in the state of Texas at the time of service in order to be eligible for Tele-psychiatry services from my provider.
• I have a right to file a complaint with the Texas Medical Board. Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018 Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353 For more information please visit our website at www.tmb.state.tx.us
1) Address and telephone number of the patient at time of session. This is to ensure that your clinician is aware of alternative means of treatment should an emergency occur
1) Due to Texas state law regarding tele-psychiatry, The Morrison Clinic will require an in office appointment within 72 hours if a new condition is treated in your tele-psychiatry appointment. 2) The Morrison Clinic reserves the right to assess suitability and appropriateness of tele-psychiatry candidates due to the potential limitations of the treatment modality mentioned above.3) In the event of imminent danger, the provider is legally and ethically bound to report information to authorities, family members, or others, to minimize potential harm.
1) New visits
“No-shows” will be charged 100% of the assigned fee
Cancellations within 48 business hours of appointment time will be charged $140.
Cancellations outside of 48 business hours of appointment time: we will gladly reschedule, and no fee will be charged.
I have read and understand the information provided above regarding Tele-psychiatry.
I have discussed it with my provider and all of my questions have been answered to my satisfaction.
My signature below affirms that I hereby give my informed consent for the use of Tele-psychiatry in my health care and authorize my provider to use Tele-psychiatry in the course of my diagnosis and treatment.